Opportunistic Screening for Chlamydia at a Community Based Contraceptive Service for Young People

From CDC National Prevention Information Network

June 17, 2003

Chlamydia trachomatis is the most common curable sexually transmitted bacterial infection in England and is the most preventable cause of infertility in women. Despite publicity campaigns, the public's awareness of chlamydia and its consequences remains inadequate, especially among young people. Fewer than an estimated 10 percent of prevalent infections are diagnosed: many women, particularly young women, go untreated and are at risk of developing severe complications such as ectopic pregnancy, pelvic pain, and tubal factor infertility. Chlamydia is also common among young men and can cause epididymitis.

A contraceptive service for young people introduced a program of opportunistic screening for genital Chlamydia trachomatis. The service is for people ages 12 to 21 years and is located in a community with a high level of social problems and economic deprivation. Experience from the contraceptive service of young women having unprotected sexual intercourse indicated that many clients with chlamydia would not have had the condition diagnosed or treated. The service gave the opportunity to introduce an opportunistic screening program to determine the feasibility of detecting and treating undiagnosed cases. The authors selected four measures of improvement: take up of the service; prevalence of previously unidentified infection; take up of treatment by positive or equivocal clients; and the percentage of treated cases that returned for test of cure screening.

Between April 2001 and March 2002, 566 (72.7 percent) young people out of the 779 who used the center's contraceptive and sexual health services who had previously not been tested for chlamydia agreed to be tested. Of the young people who had a valid result, 79 (15.2 percent) were under age 16, 166 (32.0 percent) were age 16 or 17, 121 (23.3 percent) were 18 or 19, and 153 (29.5 percent) were 20 or older; 27 (5.2 percent) were male; a total of 55 (10.6 percent) had a positive result and 58 (11.2 percent) had an equivocal result. The authors saw no significant differences between age groups or between men and women. One hundred of 113 (88.5 percent) with a positive or equivocal result were treated, of whom 65 (65.0 percent) returned for a test of cure without being recalled. All patients with positive or equivocal results were made aware of the importance of notifying all recent partners.

The screening confirmed recent study findings of high levels of undiagnosed, laboratory confirmed chlamydia infection among a high-risk group of young people. The high level of take up for the service indicates that a clinic offering contraceptive services for young women is a particularly suitable setting for chlamydia testing. Young women find testing for chlamydia in this context less stigmatizing than attending a sexual health clinic. The authors also found that clients who tested positive or equivocal had a high degree of compliance regarding treatment. This may be due to chlamydia being understood as an infection with serious implications for fertility if left untreated.

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The study demonstrated the key role of reception staff in effectively delivering services, particularly in ensuring that infected young women return for treatment. Of interest, contact would have been severely restricted without the advent of mobile phones since for nearly all young women who participated in the study the mobile phone was the preferred medium of contact.

Noninvasive urine testing was found to be acceptable for the young population. The authors did not feel that a similar degree of compliance would have been achieved by using cervical swabbing. Vaginal examinations were unacceptable for most of the clients, especially young adolescents. Test of cure was an important reassurance to clients who had been infected and came back to determine that they were clear of infection, in addition to allowing the authors to indirectly check on the take up of treatment by partners.

"The study suggests the value of routinely screening for chlamydia in clinics providing contraceptive services for young people in a community based venue," the authors concluded.

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